A 68-year-old male comes to the clinic complaining of depressed mood for the past eight months. He has lost about 5 kg during this time due to loss of appetite. He used to enjoy playing bridge with his friends, but he has not played much in the past few months. He has trouble sleeping at night and usually a drink or two helps him sleep. He lives alone and watches TV most of the day because he feels too weak to go outside. Although he feels lonely and sad, he has not considered committing suicide.
On physical examination, his motor strength is 4/5 bilaterally and deep tendon reflexes are mildly diminished. His vital signs are within normal limits. He takes amiodarone for atrial fibrillation, but otherwise, he is healthy.
What is the best next step in management of this patient?
Correct Answer B:
Depression in the elderly affects about 15% of community residents > 65 years old and up to 50% in nursing homes. They are often at high suicide risk due to social isolation, and chronic medical illness. Criteria for depression include 5 or more of the following: depressed mood, increased/decreased sleep, anhedonia (loss of interest), guilt, decreased energy, lack of concentration, increased/decreased appetite, psychomotor agitation/retardation, and suicide agitation.
The patient presents with depressive symptoms; however, before further psychiatric evaluation is done, secondary causes of depression must be ruled out (choice B). The patient is taking amiodarone, which is known to cause thyroid dysfunction and hypothyroidism can masquerade as depression.
→ Admit him to the hospital immediately and put him on suicide watch (choice A) is incorrect. Since the patient has no suicide ideation, there is no need to admit him to the hospital.
→ Test for Alzheimer's disease and prescribe donepezil (choice C) is not the best next step since the patient's presentation does not indicate any signs of dementia or inability to perform activities of daily living.
→ Treat with St. John's wort (choice D) is not the best next step. Since secondary causes have not been ruled out, medication should not be prescribed at this time. Also, St. John’s wort is not the first line treatment for major depressive disorder.
→ Treat with sertraline (choice E) is not the best next step. Although sertraline is an SSRI, first line treatment for major depressive disorder, secondary causes need to be ruled out first and medications should not be prescribed at this time.
Key point:
Depression in the elderly is common and this population is often at risk for suicide. Before primary depressive disorder can be diagnosed, secondary causes due to medical conditions such as hypothyroidism, electrolyte imbalance, and anemia need to be ruled out first.
A 25-year-old white female comes to your office complaining of abdominal pain. She requests that you hospitalize her and do whatever is necessary to get rid of the pain that has been present for a number of years. She has difficulty describing the pain. She is a single parent, and becomes defensive when asked about her previous marriage, stating only that her former husband is an alcoholic, “just like my father”.
Her previous medical history includes an appendectomy, a cholecystectomy, and a hysterectomy. On physical examination she appears healthy and a CBC, erythrocyte sedimentation rate, serum amylase level, serum electrolyte levels, and multiple chemical profile are all normal.
Management of this patient should include which one of the following?
Correct Answer E:
Somatoform disorder is often encountered in family practice. Studies have documented that 5% of patients meet the criteria for somatization disorder, while another 4% have borderline somatization disorder. Most of these patients are female and have a low socioeconomic status. They have a high utilization of medical services, usually reflected by a thick medical chart, and are often single parents. As a rule, physicians tend to be less satisfied with the care rendered to these patients as opposed to those without the disorder. Patients with multiple unexplained physical symptoms have been described as functionally disabled, spending an average of one week per month in bed. Many of these patients seek and are ultimately granted surgical procedures, and it is not uncommon for them to have multiple procedures, especially involving the pelvic area. Often there are associated psychiatric symptoms such as anxiety, depression, suicidal threats, alcohol or drug abuse, interpersonal or occupational difficulties, and antisocial behavior. A background of a dysfunctional family unit in which one or both parents abused alcohol or drugs or were somatically preoccupied is also quite common. Unfortunately, these individuals tend to marry alcohol abusers, and thus continue the pattern of dysfunctional family life.
Treatment of somatoform disorder should be by one primary physician where an established relationship and regular visits (choice E) can curtail the dramatic symptoms that many times lead to hospitalization. The family physician is in a position to monitor family dynamics and provide direction on such issues as alcoholism and child abuse. Knowing the patient well helps to avoid unnecessary hospitalization, diagnostic procedures, surgery, and laboratory tests. These should be done only if clearly indicated. Psychotrophic medications should be avoided except when clearly indicated, as medications reinforce the sick role, may be abused, and may be used for suicidal gestures. Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems.
A 33-year-old female with a chronic history of schizophrenia presents with agitation and disorientation. She was diagnosed with schizophrenia ten years ago and has been managed with the same medication. According to her family, she has been consuming large quantities of water per day. She explains that 'the voices' told her to drink more water.
Physical examination does not reveal any neurologic deficits.
Which of the following is the most appropriate initial step in managing this patient?
Correct Answer A:
Psychogenic polydipsia (PPD) is characterized by excessive water consumption in the absence of a physiologic stimulus like thirst. As many as 20% of schizophrenics are polydipsic and 3.5-5% of all schizophrenics will develop symptoms of hyponatremia. Chronicity and the length of course of schizophrenia is reported to be associated with polydipsia. Excessive water intake is well tolerated unless hyponatremia occurs. Hyponatremia presents with neurological abnormalities such as loss of energy, confusion, disorientation, seizures, or coma. Patients will not show any signs of dehydration or edema.
The first step is to assess volume status to determine the cause and treatment:
The question mentions the patient has been drinking large quantities of water per day. A volume greater than 14L/day has been reported to be associated with symptoms of hyponatremia. The usually recommended 8 glasses of water is approximately 2.2L. In the absence of any other details in the history, psychogenic polydipsia with hyponatremia is the most likely diagnosis. This patient being agitated and disoriented is showing symptoms of hyponatremia. This condition can be life threatening as serum sodium is diluted and leads to hyponatremia causing seizures. If untreated, hyponatremia can lead to coma. Hence the best initial step to manage this patient is measuring serum sodium concentration (choice A).
PPD treatment goals consist of restricting water consumption to 2-3L/day. Patient psychotic medications should also be reviewed; switching from typical to atypical medications has been shown to efficacy in treating PPD. Also consider administering ACE inhibitors. In clinical trials 60% of patients taking ACE inhibitors had a decrease in water consumption.
→ Serum glucose (B) is included in the serum electrolytes panel and is important in excluding other causes. However, due to a history of excessive water intake and presenting symptoms of agitation and disorientation without any symptoms of peripheral neuropathy serum glucose will not add much value.
→ There is no reason for ordering a head CT (C) or electroencephalogram (EEG) (D) as the physical examination does not reveal any significant findings that would indicate the need for these investigations.
→ Urine toxicology screen (E) can be ordered but is not the best initial step, given no history of drug abuse.
The question describes a patient with psychogenic polydipsia. A serum sodium level is critical in these patients due to the dilutional effect of water leading to hyponatremia causing symptoms like nausea, vomiting, loss of energy, muscle weakness, agitation, disorientation and seizures.
A 36-year-old woman comes to her gynecologist because of a three-month history of amenorrhea. Until this time, her menstrual periods had been regular. She also complains of decreased sex drive, worsening over the past couple of months. The patient denies any other symptoms. She has no significant medical history, although she started seeing a psychiatrist five months ago after a brief hospitalization during which she was diagnosed with major depressive disorder, severe, with psychotic features. Her depressive symptoms are resolving.
Which of the following medications is most likely responsible for the patient's presenting complaints during her visit to her gynecologist?
Correct Answer C:
Risperidone is an atypical antipsychotic agent. Conventional antipsychotics are clearly associated with elevations in plasma prolactin concentrations due to blockade in the tuberoinfundibular dopaminergic pathway. Dopamine binds to pituitary lactotrophs to inhibit the release of prolactin. Conventional antipsychotics block dopamine receptors, which releases this inhibition. The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except for risperidone, which is associated with elevated prolactin. Antipsychotic-induced hyperprolactinemia may cause side effects including amenorrhea and infertility, sexual dysfunction, galactorrhea, and weight gain. Given this patient's non-contributory medical history and lack of other symptoms, the onset of her complaints correlates with the initiation of treatment for psychotic depression. A morning plasma prolactin level should be obtained.
→ Fluoxetine (choice A) is a selective serotonin reuptake inhibitor (SSRI). It does not cause significant elevations in serum prolactin. Although SSRIs are commonly associated with sexual side effects, including diminished libido, but especially delayed orgasm, they are not associated with amenorrhea.
→ Quetiapine (choice B) is an atypical antipsychotic agent that is not associated with significant or persistent elevations in plasma prolactin concentrations, unlike risperidone.
→ Trazodone (choice D) is an older antidepressant agent that is commonly used for insomnia associated with depression. Although it may cause sexual side effects, it does not interfere with menstruation.
→ Venlafaxine (choice E) is a serotonin and norepinephrine reuptake inhibitor that may cause sexual side effects, but does not cause amenorrhea.
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